Gastroesophageal Reflux Disease (GERD)

BACKGROUND

Description

Gastroesophageal reflux disease (GERD) is a chronic, progressive disorder involving the backward flow of gastroduodenal contents into the esophagus. GERD is the most common serious condition of the gastrointestinal (GI) tract. It is caused by (1) a defective lower esophageal sphincter, (2) a gastric emptying disorder, or (3) failed esophageal peristalsis.

Incidence

10% general population
15-20% developmentally disabled

Prevalence

65% of adults have experienced heartburn
44% experience monthly heartburn

Influencing Factors

Malfunction of lower esophageal sphincter (LES)
Spasticity
Kyphoscoliosis
Medications that lower LES pressure
Alcohol, tobacco, or caffeine intake
Intake of spicy food, excess fat or chocolate
Tube feeding
Overeating or eating too fast
Enteral nutrition or nasogastric tube
Delayed gastric emptying
Acid hypersecretion
Postural drainage
Immobility
Constipation
Supine positioning
Chest trauma
Pregnancy

Signs and Symptoms

Heartburn (70-85%)
Chest pain (33%)
Regurgitation (60%)
Dysphagia
Recurrent vomiting
Rumination
Upper GI bleeding
Hematemesis
Hypochromic microcytic anemia
Painful or difficult swallowing (15-20%)
Globus (“lump in the throat” sensation)
Pharyngitis
Recurrent laryngitis (not infectious)
Bronchospasm (15-20%)
Hoarseness
Coughing
Difficulty breathing
Blood in the stool
Poor weight gain

Possible Complications

Esophagitis
Stricture of esophagus (10-15%)
Barrett’s esophagus (10%)
Esophageal dysplasia
Aspiration pneumonia
Respiratory problems (5-10%)
Failure to grow and thrive in infancy
Cyanotic episodes
Hiatal hernia
Anemia
Ear, nose, throat complications (5-10%)
Hemorrhage (3%)
Behavioral disturbances
Death

MEDICAL MANAGEMENT CONSIDERATIONS

Note: These considerations are in addition to the normal medical care provided to an individual without GERD. All recommendations can be addressed through clinical examination by the primary care provider, unless otherwise noted.

Many treatments relieve symptoms of heartburn but fail to stop reflux. Because the patient does not experience pain, it is possible for the epithileal lining of the esophagus to be slowly destroyed without the physician’s knowledge, which may lead to overt cancer of the esophagus. Thus, it is very important to address symptoms of regurgitation in addition to symptoms of heartburn.

Esophagitis heals in up to 90% of cases treated with intensive medical therapy. However, these treatments do not address the underlying mechanical cause of GERD; thus, symptoms recur in more than 80% of cases within one year of medication withdrawal. In these cases, surgical therapy may be beneficial.

Diagnosis

Perform the following test(s) until diagnosis can be made. The choice of which specific test(s) to perform may depend upon the availability of the test, the qualifications and willingness of the examiner, and the ability of the patient to cooperate with the procedure.

Upper GI X-ray series (Barium swallow)
Endoscopy with esophageal biopsy
Intraesophageal pH monitoring (24 hours)- (Gold Standard)
Technetium ⁹⁹TcM scan
Esophageal manometry
Serum studies

Treatment Phase I: Lifestyle and Diet Modifications

Discourage intake of fatty foods, onions, caffeine, alcohol, tobacco, chocolate, peppermint, spearmint, carbonated beverages and citrus
Recommend small, thickened feedings
Avoid rigorous activity or prolonged lying down after eating
Remain upright or lie on side after eating
Elevate head of bed at least 6 inches
Counsel to lose weight if obese
Recommend loose-fitting clothing
Avoid bending at the waist
Avoid medications that affect lower esophageal sphincter (theophylline, thioridazine, baclofen, albutrol, etc.)
Recommend over-the-counter antacids

Treatment Phase II: Long-term Drug Therapy

Note: Consider only if lifestyle and diet modifications do not generate marked improvement.

Histamine-2 receptor blocking agents (ranitidine, cimetidine, famotidine, nazatidine) to reduce the production of stomach acid
Prokinetic agents (metoclopramide, etc.) to strengthen the lower esophageal sphincter and induce the stomach to empty faster, there are some rare, but serious, cardiac side effects for the most commonly prescribed prokinetic agent

Treatment Phase III: Aggressive Drug Therapy (70-90% effective)

Note: Consider only when no significant response to lifestyle changes or long-term drug therapy.

Higher dose of H-2 receptor blocking agents
Proton pump inhibitors (lansoprazole or omeprazole) to eliminate the production of stomach acid

Treatment Phase IV: Surgery (80-93% effective)

Surgery has been found to be more effective than medical therapy in improving symptoms and endoscopic signs of esophagitis. However, it should only be considered for individuals who:

Have failed medical management;
Opt for surgery due to age, time, or medication expense;
Have complications such as Barrett’s esophagus, stricture, ulcers;
Have excessive symptoms such as asthma, hoarseness, cough, chest pain, aspiration;
Do not have a limited life expectancy; or
Do not have co-morbid conditions that would prohibit safe surgical intervention.

The primary goals of surgical intervention for GERD are to:

Reestablish the antireflux barrier without undue side effects;
Position the lower esophageal sphincter within the abdomen where it is under positive pressure; and
Close any associated hiatal defect.

Below is a list of possible surgical procedures, although there is no clear consensus in regard to which types are superior to others for persons with developmental disabilities.

Nissen total fundoplication (for patients with normal esophageal motility)
Belsey, Toupet, or D’or partial fundoplication (for patients with compromised esophageal motility)
Pyloroplasty for those who receive fundoplication and have delayed gastric emptying
Collis gastroplasty for esophageal lengthening (70% success)
Hill arcuate ligament repair
Small-bore weighted feeding tube from nose to duodenum
Esophagectomy (consider only if dysphagia stricture and profound loss of esophageal motility)

Note: It has recently been suggested that there may exist a relationship between Helicobacter pylori infection and gastrointestinal disorders. Although this relationship has not been fully established, it may be possible that eradication of H. pylori can exacerbate gastroesophageal reflux in the general population and possibly in patients with developmental disabilities.

REFERENCES

Peer-reviewed Journal Articles/Academies

Bohmer, C.J. et al. (1997). Gastroesophageal Reflux Disease in Intellectually Disabled Individuals: Leads for Diagnosis and the Effect of Omeprazole Therapy. American Journal of Gastroenterology, 92(9) 1475-1479.

Projansky, R. et al. (1994). Symptomatic H. Pylori Infection in Young Patients With Severe Neurologic Impairment. Journal of Pediatrics,125, 750-752.

Rogers, B., Lock, T., (1996). Pediatric Dysphagia, In Developmental Disabilities in Infancy and Childhood (2nd Edition. Volume II) (Eds). A.J. Caputo., P.J. Accardo. Paul H. Brookes Publishing. Baltimore. pp 163-178.

Eicher, P.S. (1997). Feeding. In M. L. Batshaw (Ed.), Children with Disabilities (4^th ed., pp. 621-641). Baltimore: Paul H. Brookes.

Schwarz, S.M. et al. (2001). Diagnosis and Treatment of Feeding Disorders in Children with Developmental Disabilities. Pediatrics, 108, 671 – 676.

Ritter, M.P. et al. (Ed.) Organ, C.H. Jr. (1998). Treatment of Advanced Gastroesophageal Reflux Disease With Collis Gastroplasty and Belsey Partial Fundoplication. Archives of Surgery, 133(5), 523-529.

Society of American Gastrointestinal Endoscopic Surgeons, Committee on Standards of Practice. (1996). Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease. Retrieved on June 14, 2006 from http://www.lapsurgery.com/sagegerd.htm

Special Interest Groups/Other Publications

Kastner, T. (1997). Helicobacter Pylori Infection in Institutional Settings. Exceptional Health Care, (November).

Lewis, J.H. (1999). Gastroesophageal Reflux Disease. In (Ed.) M.R. Dambro, Griffith’s 5 Minute Clinical Consult.(pp. 422-423). Baltimore: Lippincott Williams & Wilkins.

Smith Consultant Group and McGowan Consultants. (1998). (Ed.) M.L. Snyder, Gastroesophageal Reflux Disease. Health and Wellness Reference Guide (pp. 215-220). Neri Productions, State of Tennessee Commission on Compliance..

Starrett, A.L. (1991). In: Developmental Disabilities in Infancy and Childhood. Eds: Capute, Arnold J. and Pasquale J. Accardo. Baltimore: Paul H. Brookes Publishing Co., Inc., pp. 184-185.

RESOURCES FOR FAMILIES

American Gastroenterological Association (AGA), 301-654-2055,

http://www.gastro.org

California Department of Developmental Services, 916-654-1690,

http://www.dds.ca.gov

California Regional Centers, 916-654-1958,

http://www.dds.ca.gov/rc/RCInfo.cfm

Digestive Disease Week, 609-848-1000,

http://www.ddw.org

International Foundation for Functional Gastrointestinal Disorders, 888-964-2001,

http://www.iffgd.org

National Digestive Diseases Clearinghouse, 212-685-3440

http://digestive.niddk.nih.gov

National Institute of Diabetes, Digestive and Kidney Diseases,

http://www.niddk.nih.gov

Pediatric/Adolescent Gastroesophageal Reflux Association (PAGER), 301-601-9541,

http://www.reflux.org

Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 310-314-2404

http://www.sages.org

ADVISORY COMMITTEE

Theodore A. Kastner, M.D., M.S.

Felice Weber Parisi, M.D., M.P.H.

Terrance D. Wardinsky, M.D.

Larry Yin, M.D., M.S.P.H., F.A.A.P.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.